Benefits Survey 2

7/31/2019 Benefits Survey 2

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Benefits Survey

Participant Company Information

Company Name

Street Address

City State Zip

Person Completing Survey

Title of Person Completing Survey

( )Phone Number

Email Address

SOURCE:hrVillage.com
http://www.hrvillage.com/http://www.hrvillage.com/http://www.hrvillage.com/


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Survey Questions Insurance

Cafeteria Plan

Which of the following insurance premiums are eligible to be deducted as pretax dollars under a section 125 cafeteria plan?

[ ] Medical Plan [ ] Dental Plan [ ] Optical Plan [ ] None [ ] Other

Medical Insurance

Does your company offer or provide medical insurance coverage for your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible for medical insurance?

[ ] Hire Date [ ] End Probation [ ] One Month [ ] Two Months [ ] Three Months [ ] Other

Are all employees eligible for coverage? [ ] Yes [ ] No

If no, which employees are not eligible? [ ] Part Time [ ] Other Please explain

Is coverage paid for by the Company? [ ] Yes [ ] No If yes, what percentage is company paid? %

Is dependent coverage paid for by the Company? [ ] Yes [ ] No If yes, what percentage is company paid? %

What is the monthly cost to the employee for: Employee coverage? $ Dependent coverage? $

What type of insurance do you offer? [ ] Major Medical [ ] PPO [ ] HMO [ ] Other

What is the annual deductible? $ What is the employees maximum out-of-pocket expense? $

Which of the following cost containment features does your plan utilize?

[ ] Second Opinion [ ] Pre-Certification [ ] Utilization Review [ ] None [ ] Other

How many employees are currently insured on your plan? Is your company self-insured? [ ] Yes [ ] No

Are employees responsible to pay the company portion of the premium during leaves or other extended absences? [ ] Yes [ ] No

If yes, please explain


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4/17

Survey Questions Insurance Continued

Dental Insurance

Does your company offer or provide dental insurance coverage for your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible for dental insurance?

[ ] Hire Date [ ] End Probation [ ] One Month [ ] Six months [ ] Other






What type of insurance do you offer? [ ] Traditional [ ] DMO [ ] Other

What is the annual deductible? $

What is the annual maximum benefit? [ ] $1,000 [ ] $1,500 [ ] $1,750 [ ] No Annual Limit [ ] Other




SOURCE: hrVillage.com


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Optical Insurance

Does your company offer or provide optical insurance coverage for your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible for optical insurance?







Is there a deductible? [ ] Yes [ ] No If yes, what is the annual deductible? $

Please check all components covered under your plan? [ ] Annual Eye Exam [ ] Prescription Glasses [ ] Prescription sun glasses

[ ] Prescription Safety Glasses [ ] Contacts [ ] Other

Is there a maximum benefit level? [ ] Yes [ ] No






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Life Insurance

Does your company offer or provide life insurance coverage for your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible for Life Insurance?[ ] Hire Date [ ] End Probation [ ] One Month [ ] Six months [ ] Other






What is benefit amount based on? [ ] Salary [ ] Multiple of salary _______ [ ] Fixed amount


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Short Term Disability

Does your company offer or provide short term disability coverage for your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible for short term disability?





What percentage of income does the employee receive? %

What is the elimination period before disabil ity is paid? [ ] None [ ] 5-7 days [ ] 2 weeks [ ] 30 days [ ] Other

What is the maximum number of weeks the employee is covered for?

Long Term Disability

Does your company offer or provide long term disability coverage for your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible for long term disability?





What percentage of income does the employee receive? %

What is the elimination period before disability is paid? [ ] None [ ] Three Months [ ] Six Months [ ] Other


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What is the maximum length of benefit?SOURCE: hrVillage.com


10/17

Survey Questions Paid Time Off

Vacation Pay

Does your company provide paid vacation days to your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible for vacation?

[ ] Hire Date [ ] End Probation [ ] 30 days [ ] Six months [ ] One year [ ] Other

Do all employees receive paid vacation days? [ ] Yes [ ] No


How many years of service are required to earn one week vacation time?

How many years of service are required to earn two weeks vacation time?

How many years of service are required to earn three weeks vacation time?

How many years of service are required to earn four weeks vacation time?

What is the maximum number of weeks vacation granted?

How is vacation scheduled? [ ] By employee [ ] Based on seniority [ ] By First Request [ ] Other

[ ] By Company [ ] Company wide shut down [ ] Other

How much advance notice is required?

Are employees allowed to schedule half or partial days of vacation? [ ] Yes [ ] No

Are employees allowed to be paid in lieu of taking time off? [ ] Yes [ ] No

Are employees allowed to carry over unused vacation time? [ ] Yes [ ] No

If yes, how many days can be carried over?

Do all days carried over have to be taken the following year? [ ] Yes [ ] No


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12/17

Survey Questions Paid Time Off

Sick Pay

Does your company provide paid sick days to your employees? [ ] Yes [ ] No

What length of service is required before employees are eligible to be paid for sick days?

[ ] Hire Date [ ] End Probation [ ] 3 Months [ ] 6 Months [ ] One year [ ] Other

Do all employees receive paid sick days? [ ] Yes [ ] No


How many sick days are earned after one year of service?

How many sick days are earned after two years of service?

What is the maximum number of sick days granted?

Are employees eligible to accrue unused sick days? [ ] Yes [ ] No

If yes, how many days can be accrued?

Are employees allowed to use sick days for half or partial days? [ ] Yes [ ] No

Besides employee illnesses, which of the following qualify for sick time under your policy?

[ ] Illness family member [ ] Doctor appointment [ ] Personal Reasons [ ] No explanation required [ ] None



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15/17

Survey Questions Retirement



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Survey Questions Miscellaneous Benefits

Miscellaneous Benefits

Does your company provide the any of following amenities on site?

[ ] Child Day Care [ ] Health Club [ ] Cafeteria with food service [ ] ATM [ ] None [ ] Other

Does your company provide any of the following?

[ ] ESOP Plan [ ] Stock [ ] Stock Options [ ] None

Does your company provide educational assistance? [ ] Yes [ ] No

Does you company provide an EAP plan? [ ] Yes [ ] No

Does your company have a severance plan? [ ] Yes [ ] No

Does your company have a casual attire day? [ ] Yes [ ] No

Does your company offer employees the option of flexible time? [ ] Yes [ ] No

Does your company offer employees the option to work at home? [ ] Yes [ ] No


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Documents

Benefits Survey 2